Some guidelines (eg. NCCN - National Comprehensive Cancer Network) suggest that men with small amounts of Gleason 4 (these are men with ISUP GG 2) on their biopsy can go onto active surveillance if other factors are suitable. But not much is known about long-term outcomes compared to that in men in the low risk Gleason score 3+3/Grade Group 1 group.

This study looked at the outcomes of both groups, but for men treated with surgery, to see if the cancer outcomes were equivalent. This is a roundabout way of seeing if active surveillance is safe in men in ISUP GG 2.

The findings showed that 94% of low GG1 and 83% of GG2 had prostate cancer that had not spread beyond the prostate. Invasion into the seminal vesicles was present in 2% of GG1 and in 5% of GG2. Cancer in lymph nodes was seen in 0.3% of GG1 abnd 2% of GG2.

The need for further (radiotherapy) treatment in the future was 6% in GG1 versus 12% in GG2. Finally, PSA remained undetectable in 89% of GG1 and 81% of GG2.

It is very common to find ‘inflammation’ on a prostate biopsy – 60-80% of biopsies may show this. It has long been debated whether inflammation is a risk factor for future prostate cancer and this has been unclear. This study was not a clinical study, but rather an examination of the medical literature for all studies reporting this finding.

The presence of inflammation was associated with a lower risk of finding subsequent prostate cancer in 25 studies. Both ‘acute’ and ‘chronic’ inflammation were associated with a reduction in prostate cancer risk.

The Gleason score has been ‘replaced’ by the ISUP Group for the scoring of the agressiveness of prostate cancer on biopsy or after radical prostatectomy. See below for a descritpion of the new scoring system:

Active surveillance for prostate cancer – how often do we see no cancer on a second biopsy?

Role of Surveillance Biopsy with No Cancer as a Prognostic Marker for Reclassification: Results from the Canary Prostate Active Surveillance Study. European Urology Volume 73, Issue 5, Pages 706–712

In this study, men on AS for prostate cancer were re-biopsied (surveillance biopsies) as per protocol. On first surveillance biopsy, 32% of men had no cancer, 43% had cancer that was the same ISUP group (Gleason score) as the first biopsy, and 25% had a change in the score on their biopsy.

For those men who had no change or no cancer on the first surveillance biopsy, when they came to their second surveillance biopsy, 38% had no cancer, 44% had the same cancer as originally, and 17% were reclassified. A finding of no cancer on the second surveillance biopsy meant men were less likely to have an upgrading in their cancer in the future. This means that it may be possible to slightly relax the frequency of surveillance in men who have a surveillance biopsy without cancer. It also means that for active surveillance protocols, one size does not fit all, and the frequency of follow up for prostate cancer needs to be tailored for the individual.

If you would like to discuss active surveillance for prostate cancer, please ask you GP to contact Nick Brook and this can be arranged.

Infections associated with prostate biopsy have increased over time, and there is growing evidence of infections that are resistant to the antibiotics used to prevent infection.

Resistant infections after trans-rectal prostate biopsy (TRUS)

About 1-2% of patients who have a TRUS biopsy of the prostate will develop a febrile infection, which can be serious. Antibiotics (usually ciprofloxacin) are used before and after biopsy to keep this infection rate at 1-2%. However, there is increasing evidence that many of us carry bacteria in our gut (and rectum, where the needle is passed through to reach the prostate) that are resistant to ciprofloxacin.

A recent study from the Journal of Urology (Liss et al.) looked at 2673 men from 6 different medical centres undergoing biopsy and discovered cirpofloxacin-resistant bacteria in the rectum in 20.5% of men.

We know that some men are at increased risk of carrying such resistant bacteria (known as ESBL), and these include men who have been treated with ciprofloxacin in the prior six months, and those that have travelled to SE Asia or the Indian subcontinent in the recent past. The bacteria are harmless in the gut, but become dangerous if seeded into the prostate by biopsy.

How can the risk of infection be reduced?

One of the ways to reduce the risk of infection is to consider a transperineal biopsy instead of a transrectal biopsy. In transperineal biopsy, the needles for biopsy are not passed through the rectum, but instead through the skin of the perineum, and the infection risk is greatly reduced. A study from Jeremy Grummet in Melbourne demonstrated a reduction in serious infection, with a greater than 10x reduction in risk compared to transrectal biopsy.

You can read more about this study by following this link to an article by Jeremy Grummet.

From 1 December 2014, a new drug for advanced prostate cancer will be available and listed on the PBS. Enzalutamide is an oral drug used for advanced prostate cancer (metastatic castration resistant prostate cancer). It works by inhibiting binding of androgens (such as testosterone) to the androgen receptor (AR), as well as inhibiting the AR from entering the cell nucleus and from binding to DNA. It has had encouraging results in clinical trials.

What are the PBS criteria for enzalutamide?

The treatment cannot be used in combination with chemotherapy (docetaxel in the common chemotherapy agent used in advanced prostate cancer)

AND

The patient must have failed treatment with docetaxel due to resistance (this generally means progression of disease or non-response to docetaxel) or intolerance

OR

The patient must be unsuitable for docetaxel treatment on the basis of predicted intolerance to docetaxel

AND

Patient must have a World Health Organisation Performance Status of 2 or less (this means good performance)

AND

The patient must not receive PBS-subsidised treatment with this drug if progressive disease develops while on this drug

AND

The patient must not have received prior treatment with abiraterone

OR

Patient must have developed intolerance to abiraterone of a severity necessitating permanent withdrawal of abiraterone.